A combined ERCP/PTHC procedure was conducted the following day with the aim of grasping a wire passed through the catheter using the endoscope to…

Question -A combined ERCP/PTHC procedure was conducted the followingday with the aim of grasping a wire passed through the catheter using the endoscope to pull up the wire, allowing endoscopic access. Thereafter, a sphincterotomy was performed and once access was obtained, a balloon was introduced through the endoscope and inflated to dilate the sphincterotomy and to pull the stone out (figure 5). Adequate balloon dilation allowed for successful stone extraction into the duodenum. A 7/7 pigtail stent was inserted to prevent recurrence of ascending cholangitis and the transhepatic catheter was removed. -The case became more complicated due to the ampulla of Vater being located within a large PAD. It has been shown that PADs make ERCP more difficult and are associated with a higher complication rate.1 It also raises the question as to whether the presence of a PAD is associated with a greater risk of CBDSs within the CBD. A possible mechanism is that the sphincter of Oddi becomes incompetent and there is duodenal bacterial growth in and around the PAD.2 This results in the bile duct becoming colonised with bacteria producing β-glucuronidase which converts conjugated bilirubin into unconjugated bilirubin. This unconjugated bilirubin can combine with biliary calcium to form insoluble calcium bilirubinate stones within the CBD.3 It has also been proposed that PADs may compress the lower end of the CBD, resulting in obstructive jaundice and predisposition to stone development.4 -As illustrated in this case, a major concern when investigating and managing patients with a PAD is the higher failure rate associated with endoscopic procedures. PADs have been shown to be more common with advancing age, which further limits diagnostic and therapeutic options.5 A combined ERCP/PTHC procedure was conducted in this case because endoscopic access alone was not possible. The internal catheter that was inserted into the CBD transhepatically provided the internal-external extension in order to drain the bile so that the subsequent ERCP would be successful in removing the CBDS. Normally in the non-operative management of CBDSs, the aim is to avoid PTHC as the procedure is more invasive and has higher associated morbidity than endoscopic procedures. However, the altered anatomy due to the presence of the PAD meant that biliary access was difficult with an ERCP procedure. Access to the biliary system is through the liver. The right costophrenic sulcus can be visualised on inspiration, and the puncture site is the mid-axillary line at an intercostal space caudal to this sulcus. Once access is obtained through the CBD, a contrast medium is injected which can reveal CBDSs. -Endoscopic procedures combined with radiological guidance have advanced significantly over the last 30 years. From being primarily diagnostic, ERCP is now carried out with a therapeutic aim and has provided a highly successful alternative to surgery in the management of CBDS. However in complicated cases where a PAD is present, ERCP should be conducted with caution and by experienced endoscopists. -make a case study and please include well explain answer Health Science Science Nursing BIO 345V Share QuestionEmailCopy link Comments (0)